yes, the patients who have a mental health disorder may have other chronic illnesses and, as such, when they don't take care of their mental health, they may not take care of their overall body's health, too. other things may get ignored, and whenever you ignore a problem and let it fester, you can imagine that the cost to health care becomes triple that which you could have done had you just spent the money in prevention in the firsthand. so every $1 you spend in prevention you are saving another $3 in health on the other end. you know, as a country we do such a good job taking care of people's physical health, right? correct. we have all kinds of fancy diagnoses and machines and all of those kinds of things, but when it comes to behavioral and mental and substance abuse issues, which really do contribute to all of those things, we don't do such a good job, do we? no, we don't. those efforts really need to be enforced and supplemented. unfortunately, here in the district of columbia, we have some great programs that need funding and implementation.

we know that we can do screening and brief intervention, but we need to get more referral centers so that once we get them identified, then we actually can provide some help for people. and fran, what are the recommended strategies? what does the research tell us in terms of the strategies to use to begin to address these problems? for behavioral health and substance abuse, mental illness and substance abuse prevention programs, we want to get to the young people first. so we have several programs that target the zero to 8 population. and, obviously, we don't teach young people at that age how not to drink or look at them for behavioral health issues, but we are looking at the families and the parents and the communities that they live in. and that is what these programs do. we go in, we do an assessment. we take an evidence-based program, we implement the program that is targeted to the specific needs of that

particular community, family, school, environment as a whole. we need to get in early and often. and jordan, when you were going through your whole ordeal, were you able to really connect with the broader community? did you find support within that community? it was difficult for me, personally, to find support in our community because mental health in the suburb area that i lived in, it was such a hush-hush topic. it was very taboo. sort of a stigma associated with it? yes. absolutely, stigma. and the problem for me was that when someone asked me how i was doing or how i was feeling, i was ashamed to say because here i suffer from depression, but i went to school with this mask on my face like i didn't. although it took all the way until 10th grade for me to be diagnosed with depression, in a way when i hear about the screening that we do for physicals, you know, every year that they do for schools, i am thinking to myself,

physically we do screening for physicals every year, but how come we can't do that mentally? elementary school, just like you do that for physical things, why can't we do that mentally for children as well? and start it at the elementary age. so, i would have known that in elementary school, what i was going through were symptoms of depression, middle school all the way into high school. and i wish that was something that was implemented in my community. jane, what is a prevention-prepared community? that is a really good question, ivette, and it is a term i think we are going to be hearing a lot more. the notion of a prevention-prepared community is all of the systems in the community, be they the health care sector, the business sector, families, schools, neighborhoods, law enforcement, they are all prepared to create a prevention system for the community that really does increase the likelihood that everybody will be making an important contribution together and rates of these problems will actually decrease over time.

dr. greene, you mentioned screening and brief interventions. many people in the audience may not know what this program is all about. do you want to tell us a little more? i will be happy to, yvette. one of the things that howard university and howard university hospital has identified was that we have a large population of at-risk drinkers, substance abuse patients, and that we wanted to find a way to try to really help our population. we didn't have enough social workers or frontline people to do it. so what we had done was put together a proposal to train our residents. and samhsa was very helpful in that and provided us with a grant to train our residents and our staff about screening, brief intervention, and referral for treatment. so when a patient comes in on whatever service... they may not have come in for an alcohol or substance abuse problem, but the results of the discussion may have been screening that patient just to see, is this person at risk? and once you have done that, you really go through a process of educating the residents and staff about how you can have

open-ended questions, affirmative listening, reflective listening, that really allows a person to open up and tell you what is going on. now we know physicians and health care personnel are very busy, so the training was a consinct one, but it was effective. and the studies, especially in the trauma literature, show the reduction at the moderate-risk drinkers was very impressive, by allowing the physicians to come in and do these screenings and brief intervention. and the big thing we emphasize is that we are not telling the patient what to do. we are letting them know, we are giving them the information, we know what the statistics are, now you make a decision. is this something you are interested in? are you interested in negotiating a different way of managing this? do you want to cut down from six drinks to three drinks a day? what is it that you want to do? what have you done before that has shown that you can do a reduction strategy? do you want help with this? so our goal is to really empower the patient. it is not me telling you that you need to lose weight.

you need to do this. this is the program. no. you decide for yourself that you are ready to do this, and then you feel more committed to it and why do you want to change? what are the motivating factors? and actually asking them... there is a reason why you do it, because you get something out of it. it is not all bad. there is a reason why people continue to go back to that drug. so you have to get to that root also. there is a reason why people continue with their particular drug. so empowering a larger group of health care professionals has been our mission, and we hope they will continue to carry it on in their practice and then refer them for treatment. and really sharing the responsibility for the wellness with the patient? correct. obviously it is a very important part. buy-in, absolutely. and it works, too, right? yeah, absolutely. i mean, the research shows that it really works. it does. fran, dr. greene basically told us that within screening and brief interventions there are some referral issues that you tell the patient, "this is where you may get help." what components in a community need to be engaged in support of

a program such as screening and brief interventions? almost all of the components that jane just mentioned that makes up the community. you have to have the families involved with that type of intervention and screening process. eighty percent of most of the screenings that are done with the sbirt program do not lead to a diagnosis. so what does that mean? that means only 20 percent need an actual traditional treatment. the other 80 percent need everything from a prevention program that is building awareness in education to a prevention program that is looking... targeting on their particular specific needs, whether they have a... they are living in an economic environment that is very tough for them or they are a certain ethnic group that doesn't feel like they fit well, things like that or then that they need that intervention, they are not quite into the diagnosis, but what they need is a strong program that teachers

and their physicians and their faith leaders can all rally around and help change the environment and their behaviors. very good. when we come back i want to talk about other programs that are also going to be very helpful to communities in need. we will be right back. [music] when you have a drug or alcohol problem, your whole world stops making sense. you can get help for yourself or a loved one and make sense of life again. for information, treatment referral or most importantly help call 1-800-662-help.

brought to you by the u.s. department of health and human services. [music] they decided that they wanted to have a talent show, that they would have an [inaudible] talent night and invite the whole community to show some of the positive things that kids are doing, some of the talents that they have, help the kids feel good about themselves, have a nice adult and kid, family, community get- together

and have the kids have a lot of fun planning it, preparing it, and putting it on, and have the whole thing be sponsored by the drug-free coalition, so the message being, we know how to have a good time, drug free. so i just wanted to talk to you guys about the talent show and what we are working on. when are we going to do the actual show? is it going to be an in-the-evening performance? an after-school performance? a prevention-prepared community is a group of concerned citizens that come together and meet, and they all have the same focus around substance abuse prevention. any community can decide it is time to make the change, and let's really try to get... let's try to rally around and energize our neighbors to address this before we have the accidents, before we have the traffic crashes, before we lose more young people to substance abuse and all the things that come with that. the coalition is willing to come together and go through

training together to make sure that they are looking at the data and the information about their community and assessing it in the correct way. and then coming up with a plan or a project that addresses their needs. i really like the idea of building the positive. it is sort of like building health instead of treating a disease. some of the specific challenges at a coalition level or a community level: engaging the key leaders, engaging the grandparents, parents of kids, and all of the sectors. bringing them in and then giving each of them a role to play and keeping that engagement over time is also a challenge. our role is facilitation. the conversations take place between the youth and the community members. usually, within these community members there is representation from law enforcement, from the business community, from the

faith community, from elected officials, parents, students. i'm not with my 15-year-old 24/7, you know, i'm with her... i work at the school so i am here, but i don't see her every day. i don't see her in between classes, and it is good that there is reinforcement to back me up, saying, you know, "don't drink, don't use tobacco products." you need to have the prevention to keep... to keep these risk factors either away or down to a minimum with youth. show alternative ways to spend your time, i think that is probably the ideal thing. and prevention is probably a lot easier since you aren't already addicted to anything, then having to quit later and going to rehab. like i always say, i don't want to do that. i want to finish school and go to college. in this club you get to help people and you get to tell people what things not to do, like i have experience with background, like with drugs and stuff,

and i don't want to go down that road. i want to go down a different road. so that's why i am in this group. as a community we are after the same goals and knowing that we can work together and we can bring positive change to the community is always very rewarding. dr. greene, going back to screening and brief interventions, are there certain competencies that need to be highlighted while trying to implement that program? definitely. the cultural competency piece is a specific part of our know the risk sbirt program at howard university. we wanted to make sure that people understood that communicating to one group versus another may require some refinement. you may need to know where the people are coming from, what their background is, so we try to incorporate this through a web-based program, education as well as through lectures and didactics and role playing so that the residents actually get a chance to get a understanding. so, when they come and actually talk to the person,

they have some sense of history of who this person may be and why they are. and maybe why they don't want to come and seek treatment. and how is that accepted among the folks that have been trained in the sbirt methodology? well, the sbirt methodology has, i would say, taken a great role in not only improving the way they communicate for sbirt but all communication. because they have to learn how to talk with patients of different cultures for many different reasons. it may not just be sbirt that they are talking about, but they take these same skills, this open-ended listening and reflective listening, back to their own patient population for other reasons also. and they also incorporate... i know that we were talking about previously the whole issue of families not wanting to accept that there is a mental illness because they feel somehow people may discriminate against them, and some people call it stigma, but it is really a discriminatory practice to not

be able to accept the medical condition within the family. so i suspect they need to also learn about those issues. definitely. learning about the whole spectrum improves the health care provider and what they can provide, what assistance they can provide to their patients. and, fran, let's go back and talk about... most of what we have been referring to has to do with alcohol and drug disorders. how about the mentally ill or the people with mental health problems? is it similar? are we learning to adapt sbirt for that community as well? yes, in particular sbirt now is a billable service under health insurance for screening for depression. and that is a big leap that, combined with parity legislation, that has allowed us now to health insurance, now have to pay for mental health services. both of these may be small steps in some respect are huge steps

in our field because it helps take care of that discrimination and helps people become a little bit more accepting. that we are talking about health, major health conditions that they may be mental health, they may be emotional health. and as a matter of fact... language is important, emotional health transcends to all of what we are talking about today under behavioral health. because if you are emotionally healthy you have a strong character, you have confidence in yourself, your family is emotionally healthy. we're looking at lowering risk for behavioral health problems across the board. and of course our audience needs to realize that under the parity law small businesses of more than 50 people that are already covering certain conditions need to also cover mental health conditions as well, correct? correct, and some of your listeners may not realize that that has not been done before. and that is one of the reasons why parents struggle and why

they may not talk to their young people at a younger age simply because they can't afford it. so what would you do as a parent? you have something you can't really talk to anybody about, you don't quite understand it yourself, and your doctor is saying to you, "well, if you want these services you've to figure out how to pay for it." our whole health care system now is changing and so will the health of our country. jordan, given your experiences and the fact that you speak to parents, that you speak to populations within school systems, what do you think the communities really need to begin to do better in order to address some of these issues? i think that one thing, and i mentioned earlier, was that kids need to feel and young adults need to feel as though they are not the only ones going through what they are. not just by their parents but other people around them of the same age. you know, there was a statistic in the early 2000s, in 2001, 2002, that even though 20 to 25 percent of young adults will suffer from a mental disorder in a given year, up to two thirds of those kids won't seek help.

and a lot of that is because of that stigma and the fact that kids don't know if other kids are going through these topics or issues because there's no discussion. and that is what i try and promote when i go to speak at these schools. not just to talk to each other inside the school but inside the entire community of all ages and to implement programs, whether it is peer mediation between the students or whether it is different activity nights for all ages to again continue the dialogue of mental health. jane, we've talked about screening and brief interventions. talk to us about what the institute does at cadca and how it offers community an opportunity to really get engaged. well, i will try to be brief, ivette, because as you know that is my favorite topic. what we do at the community anti-drug coalition institute is we work with communities throughout the nation to help them become prevention-prepared communities and get all of the different segments of the community working together

to not only implement programs but also change systems and policies and practices and environments to once again have a comprehensive approach to these problems. so, we're more likely as a nation to have communities that are tackling these problems in serious and significant ways, which actually lead to results. and how do you do it? what is done? how can someone contact you and make sure that they have access to the information, to the training. i suspect that you do training. for your audience, you can get in touch with us at cadca, c-a-d-c-a dot o-r-g. go to our web site and all of the information is available there, and what i am really pleased about is the fact that we really do have the capacity and the reach to help communities start what we call community coalitions. and how do they do that? they do that by bringing community members together, different segments of the community together to identify

local conditions that are important in their communities to address and then developing strategies where all of the different segments of the community work together to alleviate those problems. it's what americans do. you know, ivette, when there is a problem you get everybody together and you work together to solve it. and there are ways that you can do it effectively. and what we try to do at the institute is help communities actually do those things effectively. fran, do you have an example of a really good model of, you know, a prevention-prepared community? actually, yes, and jane and i work hand-in-hand on this. in between the federal government and our community coalitions, working through what we call the strategic prevention framework model. and basically what that means is that we teach communities, as jane has already mentioned, to do five different steps. and going in abbreviated version, you want a community to come together just to discuss the problems that they see.

do an actual assessment. they're taught how to do that so that they have data. learn how... what to do with that data and prioritize your problem, go after an evidence-based practice that will mitigate the problem and at least address it. and then, the all-important thing that we didn't used to do on a regular universal level, which is to evaluate what you just did and then you start over again. and this is a process that has been going in our communities on several different types of coalitions, both in family communities, college campus communities, rural, urban, any possible community structure you can think of across the country for the last decade, and it is really showing good results that community change is happening around the topics that we've been talking about here tonight. what are some of those good results? reduction in underage drinking. between the ages of 8 and 16 we are reducing the use of

alcohol among our young people. however, we are seeing an increase between the ages of 17 and 20, 21. so that's a problem area for us, and we are working with our communities, and that is something that jane would take in her training and highlight. suicide prevention, suicide prevention going through this type of a model also is raising the awareness. we have over 4,000 young people each year die of suicide. now what is equally important is that from each suicide, each one of those 4,000 has anywhere from 1 to 200 attempts. so this is a major problem. a community, when they assess, and they have had a couple of suicides of young people in their... or older adults in their community, then they will target a program directed to that. we are seeing results of that as well. well, when we come back i want to go back to talking about some

of the other programs that exist, and i want to see what... how hospitals and how youth organizations can also get in the mix to solve all of these problems. we'll be right back. for more information on national recovery month , to find out how to get involved, or to locate an event near you, visit the recovery month web site at recoverymonth.gov. they tell me i was there but i don't remember. i don't know where i really was. i do not know what i had for breakfast. i do not know who won the game. i don't recognize this man. if you or someone you know is struggling with a drug or alcohol problem, there is a solution. recovery. call 1-800-662-help for information and for hope. through treatment my life's a whole lot brighter now. brought to you by the u.s. department of health and human services

[music] so, screening and brief intervention is what we call a secondary prevention approach. so, it is a way of intercepting people who might be already engaging in risky substance abuse behavior and trying to reduce their abuse and reduce the harm that they might experience from their substance use. we decided to do our intervention in this mental health clinic. and that's something that hadn't been done before, so we decided to use this very brief screening and brief intervention tool called the assist. it is the alcohol smoking and substance involvement

screening test, which was developed by the world health organization. well, we use the assist results in intervention planning quite immediately; that is part of the beauty of the assist, that it has kind of a built-in intervention that, based on the score that is deduced from the eight questions of the assist, you are kind of guided to do a validating response, a brief intervention, or an intervention with kind of a referral to treatment or a discussion about kind of getting further treatment. and in that assist they'll provide much more detailed information on their pattern of usage of various substances. we have a fair amount of detail that we end up with as a result of their completing the computerized assist. one of the things we use with the assist results is kind of looking at how maybe the substance use is impacting the current... their presenting issues. if it is depression or anxiety, maybe how the substance use is exacerbating that, and we will give some education about that, the risk factors, and then we will also explore the consequences with respect to the presenting concerns.

over the course of counseling, we will actively look at the student's ambivalence or values with respect to the substance use as it relates to the presenting concerns. well, our program here, i think, is a really great resource for ucla. not only do the students here benefit from the screening and brief intervention services, but the health center here on campus is referring students here who they feel might be at risk for substance use. one of the lessons we learned from the research we did here was that for students who really have a high score on the assist, who are at risk for what we call chemical dependency. it is very hard to convince someone that, just because they are having a lot of negative consequences from what they are doing, that they should get treatment for that. so we really needed an intermediary step; you know, no matter how at risk they are, most people... it is a hallmark of substance abuse if they just don't feel that at risk. when we recognize that a student requires more extensive treatment or intervention related to a chemical dependency issue, we collaborate with a substance abuse and dependence

treatment facility that is actually located near campus, named the matrix institute, and it is also covered under the student health insurance plan. we also need to address the broader environment. so we need to look at ways of making alcohol and drugs less accessible to students, and so it is very important to have the one-on-one interventions, but also to have the broader environmental strategies and policy strategies to address this problem comprehensively. dr. greene, we were talking about certain prevention-prepared communities. within that can you talk a little bit about what role hospitals... and you know-and we are using howard university hospital as an example-are doing or should be doing in order to engage in these efforts? i am glad you asked that question, ivette. the hospital has suicide prevention, suicide groups

as well as recover... people who have recovered from post-traumatic stress disorder. so there are some groups to help and address some of these issues, but there is still a larger community that we need to get help to. the identifying and screening, not only for just substance abuse but for the mental health that jordan was talking about previously so you can identify patients a little earlier. you start seeing the patterns: this person got shot last year, now they got shot this year, they're under the age of 17 and as a trend may go... that third time may be a fatal one. so getting the family involved, getting the child protective services, getting our community involved to really try to address some of the greater issues that may be going on and not just putting the patient right back out on the street, but you need resources and an organized community and support system. you may be able to identify it, but if you can't send the patient anywhere to get that help, your identification becomes a stopping point.

so we really want to encourage the acquisition of more resources. similarly, with our sbirt program we have a great apra-system but because of our inability... what is an apra-system? apra is our intake center that helps to send patients who need to go into a recovery program; whatever the recovery program may be, it helps to identify beds that are open in the city. what we would like to do is to really be able to have that interposition point, somewhere where you can take the person in so they don't have to go back out on the street before they can get into the intake system. very good. our concerns are that we may be losing people. they may have agreed to go into the system, but they had to go back out on the street first and now they didn't come back. so we feel... and then the beds may not be available for a long time, and that becomes a concern for us also. jordan, as a person who went through the system and had support, in the ideal world, what would you have preferred